Provider Demographics
NPI:1558381244
Name:SHANNON, PATRICIA (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CLOCK TOWER CMNS
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-4055
Mailing Address - Country:US
Mailing Address - Phone:845-592-4915
Mailing Address - Fax:
Practice Address - Street 1:45 FOSTER RD
Practice Address - Street 2:
Practice Address - City:HOPEWELL JUNCTION
Practice Address - State:NY
Practice Address - Zip Code:12533-6123
Practice Address - Country:US
Practice Address - Phone:845-226-4590
Practice Address - Fax:845-226-2465
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173794207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01192630Medicaid
NY34F3310Medicare ID - Type Unspecified
NYD61113Medicare UPIN